MULDER HEALTH CARE FACILITY

713 LEONARD ST N
WEST SALEM, WI, 54669
6087861600
CCN: 525209
1
Overall
1
Health
4
Staffing
4
Quality
ChainATRIUM CENTERS
Special FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
OIG Federal Exclusion Matches (1)
This facility's name matches one or more entities on the OIG List of Excluded Individuals/Entities (LEIE). Excluded parties are prohibited from participation in Medicare and Medicaid programs.
ANCILLARY HOME HEALTH CARE
1128b8
Excluded 1999-11-18
Ownership
NameRole%
ORION OPERATING SERVICES LLC5% OR GREATER DIRECT OWNERSHIP INTEREST100%
ATRIUM CENTERS, INC.5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
BAILEY, ESSEL5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
FINNEY, DONALD5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
FINNEY, DONALDCORPORATE OFFICERNOT APPLICABLE
ALBRIGHT ROSS, SUSANCORPORATE OFFICERNOT APPLICABLE
BAILEY, ESSELCORPORATE OFFICERNOT APPLICABLE
ALBRIGHT ROSS, SUSANOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
ALBRIGHT ROSS, SUSANW-2 MANAGING EMPLOYEENOT APPLICABLE
Penalties (2)
DateTypeAmount
2025-04-14Fine$278K
2024-11-04Fine$14K
Health Deficiencies (59)
2026-01-22 · Health
E
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
E
F803 · Nutrition and Dietary Deficiencies
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
D
F692 · Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
E
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from the wrongful use of the resident's belongings or money.
2025-09-16 · Health
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
E
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
D
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
D
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
2025-04-14 · Health
L
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
F
F867 · Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
F
F838 · Administration Deficiencies
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
D
F805 · Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
E
F804 · Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
D
F745 · Quality of Life and Care Deficiencies
Provide medically-related social services to help each resident achieve the highest possible quality of life.
J
F741 · Quality of Life and Care Deficiencies
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
E
F700 · Quality of Life and Care Deficiencies
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
G
F692 · Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
E
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F686 · Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
D
F677 · Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
D
F626 · Resident Rights Deficiencies
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
D
F625 · Resident Rights Deficiencies
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
D
F624 · Resident Rights Deficiencies
Prepare residents for a safe transfer or discharge from the nursing home.
D
F623 · Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
D
F622 · Resident Rights Deficiencies
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
D
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
D
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
D
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
2024-12-16 · Health
D
F580 · Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
2024-11-04 · Health
J
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
2024-07-24 · Health
D
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
2024-02-22 · Health
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
F
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F
F801 · Nutrition and Dietary Deficiencies
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
D
F690 · Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
D
F686 · Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
D
F657 · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
D
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
D
F645 · Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
E
F550 · Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
2023-12-15 · Health
F
F887 · Infection Control Deficiencies
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
F
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
2023-10-18 · Health
D
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
D
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
2023-04-10 · Health
D
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
D
F585 · Resident Rights Deficiencies
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
E
F584 · Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
2023-03-14 · Health
F
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F660 · Resident Assessment and Care Planning Deficiencies
Plan the resident's discharge to meet the resident's goals and needs.
D
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
D
F584 · Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
2022-12-30 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
F
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F758 · Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
D
F756 · Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
G
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
D
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
D
F572 · Resident Rights Deficiencies
Give residents a notice of rights, rules, services and charges.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day
3.49
3.68
RN Hrs/Resident/Day
0.85
0.54
LPN Hrs/Resident/Day
0.56
0.81
CNA Hrs/Resident/Day
2.08
2.33
PT Hrs/Resident/Day
0.10
0.12
Data as of 2026-03-01